Urology Coding Alert

Know when you can, and when you can't, use modifiers to unbundle the newest edits

You can no longer report the implantation, removal and reinsertion of luteinizing hormone-releasing pellets with certain drug administration G codes, thanks to the latest National Correct Coding Initiative (NCCI) edits, version 11.3. The edits took effect on Oct. 1.

The newest round of edits also limits your ability to report certain radical prostatectomy procedures in addition to a complete cystectomy to Medicare on the same day. In addition, you won’t be able to report office or outpatient visits for new or established patients with certain IM and IV drug administrations.

You Can’t Use Modifiers to Break These Bundles

The last set of NCCI Edits for 2005 bundles 55842 (Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy[s] [limited pelvic lymphadenectomy]) and 55845 (... with bilateral pelvic lymphadenectomy, including external ilian, hypogastric, and obturator nodes) into 51595 (Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes). These new bundles prevent you from erroneously double-billing lymph node removal.

If your urologist performs a radical prostatectomy along with a radical cystectomy (51570-51596) on a male patient, “the AUA (American Urological Association) advises that both the cystectomy and the prostatectomy can be coded,” says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC, a 31-urologist practice in Indianapolis. But the code descriptor for 51595 lists lymph node dissection. Therefore, the NCCI version 11.3 bundling of 55842 and 55845 into 51595 prevents duplicate billing for the lymph node removal and dissection.

How you should report it: Your urologist performs a radical cystectomy with urinary diversion by loop with PLND and a radical prostatectomy. (The combination of these two procedures is also known as a radical cystoprostatectomy, Hause says.) You should report 51595 for the radical cystectomy and 55840 (Prostatectomy, retropubic radical, with or without nerve sparing) for the radical prostatectomy, says Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology at the State University of New York, Stony Brook.

The code descriptors for 55842 and 55845 include nodes. Because 51595 includes a node resection, you can’t bill these radical prostatectomy codes with 51595. You can, however, bill the 51595 code with 55840 because this code refers to a radical prostatectomy without nodes, Ferragamo says.

Note: These two new bundles are non-mutually exclusive, which means you can’t use a modifier to ever report 55842 or 55845 with 51595.

Drug Administration Codes G0351-G0354 Get Bundled Again

Version 11.3 also bundles G0351 (Therapeutic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), G0353 (Intravenous push, single or initial substance/drug), and G0354 (Each additional sequential intravenous push [list separately in addition to code for primary procedure]) into the following codes urologists use for the implantation, removal and reinsertion of luteinizing hormone-releasing pellets:

• 1198--Insertion, non-biodegradable drug delivery implant

• 11982--Removal, non-biodegradable drug delivery implant

• 11983--Removal with reinsertion, non-biodegradable drug delivery implant.

“This edit is probably to prevent the incorrect duplicate billing of drug administrations by use of more than one administration code,” Hause says.

You can use modifier 59 (Distinct procedural service) to unbundle these codes, Ferragamo says.

Example: A urologist reinserts a Viadur implant into the forearm of a patient who has carcinoma of the prostate, and later that day gives an intravenous push of 4 mg of Zometa. Your coding should include 11983 for the Viadur implant and G0353 for the Zometa. Append modifier 59 to G0353 to bypass the edit of these services because your urologist performed the services on the same day but at separate patient encounters. Use J9219 (Leuprolide acetate implant, 65 mg) for the Viadur implant and J3487 (Injection, zoledronic acid, 1 mg) for the Zometa administration.

Edits Further Restrict Your E/M Coding

You can no longer report the following E/M codes with the IM and IV injection codes G0351 and G0353 without using a modifier:

• 99201-99205--Office or other outpatient visit for the evaluation and management of a new patient …

• 99212-99215--Office or other outpatient visit for the evaluation and management of an established patient …

When the E/M service is a distinctly separate service from the drug administration, you can use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to overcome these new bundles, Ferragamo says.
 
For example, your urologist examines a new patient with hypogonadism (257.2, Other testicular hypofunction). The physician then administers testosterone IM. Report 99204 (Office or other outpatient visit for the evaluation and management of a new patient ...) and append modifier 25 to this code to appropriately report the evaluation and examination. You should also report G0351 for the injection and J1080 (Injection, testosterone cypionate, 1 cc, 200 mg) for the drug itself.

Note: You still cannot report E/M code 99211 (Office or other outpatient visit for the evaluation and manage-ment of an established patient, that may not require the presence of a physician) with G0351 or G0353. NCCI bundled 99211 into G0351 and G0353 prior to version 11.3, and you can’t break these edits with any modifier.